New CAC-DAD Score Outperforms Agatston Score in Predicting Cardiac Events, Study Finds

The research, led by Dr. Gavin Huangfu from the Department of Cardiology at Fiona Stanley Hospital in Perth, Australia, and his team, assessed the prognostic value of the CAC-dispersion and density (CAC-DAD) score in comparison to the traditional AS. The study included 961 patients who underwent cardiac computed tomography (CT) scans for cardiovascular or perioperative risk assessment. The median age of participants was 67 years, and 61% were men.

Using a deep learning-based algorithm, the CAC-DAD score was calculated from noncontrast CT scans. Unlike the Agatston score, which quantifies calcium without considering its spatial distribution or density, the CAC-DAD score adjusts for both, taking into account how widely the calcium is spread in the coronary arteries and giving protective weight to denser plaques (≥1000 Hounsfield units), which are considered more stable.

The following were the key findings of the study:

• During the median follow-up of 30 days, 61 patients experienced major adverse cardiovascular events (MACE), including nonfatal myocardial infarction and cardiovascular death.
• A high CAC-DAD score (≥2050) identified 74% of MACE cases, compared to 57% identified by an Agatston score (AS) ≥400.
• Univariable analysis showed that elevated CAC-DAD scores, higher AS thresholds, older age, diabetes, hypertension, and statin use were linked to increased MACE risk.
• In multivariable analysis, only the CAC-DAD score (hazard ratio: 2.57), along with age, diabetes, and statin use, remained statistically significant predictors of MACE.
• Adding the CAC-DAD score to a predictive model containing demographic variables and the Agatston score improved the model’s accuracy, increasing the C-statistic from 0.61 to 0.66.

The findings suggest that the CAC-DAD score may offer a more refined tool for assessing cardiovascular risk, especially in patients who might appear lower risk based on traditional calcium scoring alone. The study authors highlighted that individuals with a high CAC-DAD score, even if their Agatston score is low, may still face elevated risk and should be considered for more aggressive preventive strategies.

Overall, the study supports the integration of advanced automated imaging metrics into clinical practice to enhance cardiovascular risk stratification and guide more tailored treatment approaches.

Reference:

Huangfu G, Ihdayhid AR, Kwok S, et al. Novel CAC dispersion and density score to predict myocardial infarction and cardiovascular mortality. Circ Cardiovasc Imaging. 2025;18:e018059.